What is the Mediterranean diet?

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The Mediterranean diet is based on the traditional eating habits from the 1960s of people from countries that surround the Mediterranean Sea, such as Greece, Italy, and Spain, and it encourages the consumption of fresh, seasonal, and local foods.¹ The Mediterranean diet is not a single prescribed diet, but rather a general food-based eating pattern, which is marked by local and cultural differences throughout the Mediterranean region.

So, what foods is it made up of?

The diet is generally characterised by a high intake of plant-based foods (e.g. fresh fruit and vegetables, nuts, and cereals) and olive oil, a moderate intake of fish and poultry, and low intakes of dairy products (mostly yoghurt and cheese), red and processed meats, and sweets. Wine is typically consumed in moderation and, normally, with a meal.¹ A strong focus is placed on social and cultural aspects, such as communal mealtimes, resting after eating, and regular physical activity.² Nowadays, however, the diet is no longer followed as widely as it was 30-50 years ago, as the diets of people living in these regions are becoming more ‘Westernized’ and higher in energy dense foods. ^3,4

What does the science say?

Far from being a hype diet, the health benefits linked to the Mediterranean diet are supported by scientific evidence. The Mediterranean diet is associated with lower all-cause mortality and morbidity (disease occurrence), and has been linked to numerous health benefits, including a lower risk of cancer, cognitive disease and cardiovascular disease as well as metabolic syndrome, obesity, and type 2 diabetes.^2,5

A recent publication from the World Health Organization (WHO) identified the Mediterranean diet as an effective dietary strategy to prevent and control non-communicable diseases (NCDs), which are currently the leading cause of premature death globally (under 65 years of age).² The available literature strongly suggests that Mediterranean dietary patterns are beneficial for the prevention and control of diet-related NCDs. It is also considered one of the easiest dietary patterns to follow long-term due to its flexibility and the accessibility of the characteristic foods.⁶ However, there is also some data to suggest that the association between lower risk of cardiovascular disease and the Mediterranean diet is stronger for people with higher incomes, possibly due to better access to and knowledge about healthy foods.⁷ Despite this, many people could find the Mediterranean diet to be an effective strategy to help manage weight and improve health.²

A Mediterranean-like diet is associated with lower weight in children, but has become less common in the region

A team of researchers from eight European countries have found that a diet that is very similar to the traditional Mediterranean diet is associated with lower body weight and fat percentage in children. They also found that this diet is not common among children in Mediterranean countries. The researchers were partners in the EU-funded IDEFICS study (2006-2012), one of the largest studies to investigate health effects of a changing diet, lifestyle, and social environment and develop intervention approaches for two to ten-year olds. IDEFICS is an intervention study involving 16,220 children from eight European countries (Belgium, Cyprus, Estonia, Germany, Hungary, Italy, Spain and Sweden).

Referring to a vast amount of scientific literature, the authors of the study believe that eating a diet similar to the traditional Mediterranean dietary pattern is associated with improvement in health status. This Mediterranean-like diet is based on food groups, whereas the traditional Mediterranean diet consists of foods typical of the Mediterranean region such as olive oil, almonds, citrus fruit, etc. Using food groups enables researchers to translate this dietary pattern to other regions, e.g. where different fruits or types of grain are more commonly consumed, and then to make comparisons.

In adults living in different parts of the world including Europe, the US and Australia, a high adherence to the so-called Mediterranean-like diet has been shown to reduce the risk for metabolic syndrome, morbidity and mortality related to major chronic diseases, and is associated with living longer. While many studies in children have also shown positive health effects of this dietary pattern, only few have described the association with children’s weight status or other overweight and obesity indicators such as body mass index, waist circumference or waist-to-height ratio. In particular, there is a need for studies comparing adherence to a Mediterranean-like diet in children in more European countries, with different dietary cultures, since most investigations have been performed in countries such as Spain, Greece and Italy.

In the current IDEFICS study, which was presented at the 2014 European Congress on Obesity in Sofia, Bulgaria, the researchers carried out a pan-European comparison. They tested whether following a Mediterranean-like diet was related to overweight or obesity. They looked at whether eating this diet (assessed at the beginning of the study) was related to changes in body composition after two years, including body mass index (BMI), waist circumference, waist-to-height ratio and fat mass percentage

Adherence to a Mediterranean-like diet was assessed with a questionnaire, filled out by the parents, which asked about the consumption frequencies of 43 food items, which was then scored. The score was calculated by giving one point for high intakes of each food group that was considered typical of the Mediterranean diet (vegetables, fruits and nuts, fish and cereal grains), as well as one point for low intakes of foods atypical of the Mediterranean diet (such as dairy and meat products).

An important finding of this research was that children who ate a Mediterranean-like diet were less likely to be affected by obesity or overweight, and they did not have an increased BMI and waist circumference after two years. Interestingly, the Mediterranean-like diet, at least among children, is not necessarily a feature of Mediterranean countries anymore; the researchers found that the highest adherence to a Mediterranean-like diet was in Sweden, where children had the highest scores for cereal grains, fruits, nuts and vegetable consumption. On the other hand, the lowest overall adherence rates were found for Cyprus, and the lowest intake frequencies of vegetables were observed in Italy. The highest overweight and obesity rates were observed among children in Italy (more than 40% live with obesity or overweight), followed by those in Cyprus and Spain (more than 20%).

According to the authors the results were not entirely unexpected. They stated that dietary habits, especially in southern Europe are changing, particularly among young people. Animal products and fats are increasingly consumed, while the intake of vegetable-based foodstuffs is declining. Where people in the Mediterranean countries may have moved away from their traditional dietary pattern, people in the north may have become more health conscious, the authors hypothesise.

They conclude that the promotion of dietary habits similar to a Mediterranean diet should be considered for inclusion in European childhood obesity prevention strategies. Health authorities need to focus more on the promotion of increasing the consumption of fruit, vegetables, legumes, nuts and fish among children. Moreover, their findings suggest that a Mediterranean-like diet can easily be adopted in other countries with different food cultures, such as the Nordic dietary pattern.

References

1. Willet WC, et al., (1995) Mediterranean diet pyramid: a cultural model for healthy eating The American Journal of Clinical Nutrition, 61(6), 1402S–1406S.

2. The World Health Organisation (WHO, 2018) What national and subnational interventions and policies based on Mediterranean and Nordic diets are recommended or implemented in the WHO European Region, and is there evidence of effectiveness in reducing nonc

3. Garcia-Closas R, Berenguer A, Gonzalez C (2006) Changes in food supply in Mediterranean countries from 1961 to 2001. Public Health Nutrition 9(1), 53–60.

4. Alexandratos N, (2006) The Mediterranean diet in a world context. Public Health Nutrition, 9(1a), 111-117.

5. Martinez-Gonzalez, M.A, et al. (2009) Mediterranean food pattern and the primary prevention of chronic disease: recent developments. Nutrition Reviews, 67, 111-116.

6. US News and World Report Rankings (2016) Easiest Diets to Follow.

7. Bonaccio M, et al., (2017) High adherence to the Mediterranean diet is associated with cardiovascular protection in higher but not in lower socioeconomic groups: prospective findings from the Moli-sani study. International Journal of Epidemiology, 46(5)

8. Tognon G, Hebestreit A, Lanferet A, et al. (2014). Mediterranean diet, overweight and body composition in children from eight European countries: Cross-sectional and prospective results from the IDEFICS study. Nutrition, Metabolism and Cardiovascular Diseases 24:205-213.

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